Immunizations are among the most effective and cost effective medical interventions affecting the health of children. In order to reach Healthy People 2010 goals for the immunization of preschool children there must be increased emphasis on the effective delivery of vaccines. The US Task Force on Immunization Delivery strongly recommends that pediatric providers implement some type of provider based reminder/recall system to improve immunization delivery. Yet barriers exist that prevent some practices from achieving adequate immunization delivery. Our primary hypothesis is that provider reminders focused on a particular age group (18 month olds) can be efficiently added to office based systems and increase the rate of delivery of immunizations to those children. The aims of this project are as follows: 1) Within a diverse set of private offices, determine the effectiveness of a provider prompt for needed vaccines at 19 months of age, 2) Assess the challenges and test solutions for a practice to institute a provider prompt for needed vaccines on the medical record of 18 month children within a diverse set of practices 3) Identify the challenges and test solutions to completing the immunization of 18 month old patients (becoming up to date) within a diverse set of practices, and 4) Determine predictors of successful immunization by practice and patient factors including: A. patient factor- including insurance, race, ethnicity, previous vaccine history and B. Practice factors-including practice type, location (rural, suburban, urban), patient assignment (one physician, common assignment), medical record type (electronic medical record). This project will take place in a regional practice-based research network, the South Carolina Pediatric Practice Research Network (SCPPRN), with 8 pediatric practices and approximately 133,000 visits per year. Four practices use an electronic medical record (EMR), and four use paper medical records. SCPPRN also has a diverse population of rural, suburban, and urban populations. The participating practices current procedures and practices around the delivery of immunizations will be measured and optimized for the provider reminder. Practice implementation of the provider reminder interventions are expected to be diverse, and could range from a flag system in the (EMR) to post-it notes on a paper medical chart. The implementation of the intervention will utilize practice-based quality improvement, including a face to face group training, onsite assessments and monthly conference calls. Process measures such as number of prompts, visits and vaccines delivered will be measured monthly and problems addressed. It will be critical to identify interventions that will be efficient, effective, and sustainable in the practice. Immunization rates will be measured at the beginning and the end of the study, and change in these rates within practice will be the primary outcome measure. The outcome is vaccination series complete at 19 months, as well as a measure of time it takes until up to date status is achieved. We will also compare results between practices, particularly differences between practices and patients by practice and patient characteristics. This project is designed to test whether implementation of a provider reminder/recall or prompting system will be effective in increasing the rate of immunization delivery to 18 month old children. Utilizing diverse patient populations, including poor and minority patients, the implementation of the reminder/prompting and recall system will occur in suburban, urban, and rural practice settings. [unreadable] [unreadable] [unreadable]